<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015475
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:57:21 PM

Document Has Been Signed on 12/01/2022 12:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JOHN W. MACK CENTER, USC HEAD STARTFACILITY NUMBER:
198015475
ADMINISTRATOR:DEBBIE GIPSONFACILITY TYPE:
850
ADDRESS:3020 SOUTH CATALINA STREETTELEPHONE:
(213) 743-4651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 45TOTAL ENROLLED CHILDREN: 30CENSUS: 20DATE:
12/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Joanna WilliamsTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/1/2022, about 8:40 AM, Licensing Program Analyst (LPA) T. Tran arrived at John W. Mack Center USC Head Start to conduct a Case Management inspection that was self-reported on 10/19/2022 regards a child in care was choking on a chicken nugget during lunch time. The Monterey Park South West Child Care Regional Office received the incident report on 10/26/2022. About 8:50 AM, LPA met with Joanna Williams, Associated Director who provided LPA a tour of the center. LPA observed staff and children were wearing masking indoor. LPA observed proper care and supervision and ratio.

During today's visit, LPA conducted staff and children files review. LPA interviewed staff, children, and other. LPA obtained LIC 500, staff and child documents. On the day of the incident, there was a fully qualified teacher and a fully qualified teacher assistant supervised 14 children. When the incident occurred, staff observed the incident immediately performed Heimlich Maneuver and removed the chicken nugget. Child observed to fine and parent was contacted in a timely manner. There was no impacted to other children in the classroom that witnessed the incident. No 911 calls or medical treatments required. Based on the information that were gathered during today's interviews, it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.

No deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Joanna Williams.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1